History

Otalgia, ranging from mild to severe, typically progressing over 1-2 days

Hearing loss

Ear fullness or pressure

Tinnitus

Fever (occasionally)

Itching (especially in fungal OE or chronic OE)

Severe deep pain – If this is experienced by a patient who is immunocompromised or diabetic, be alerted to the possibility of necrotizing (malignant) OE

Discharge – Initially, the discharge may be clear and odorless, but it quickly becomes purulent and foul-smelling

Bilateral symptoms (rare)

Frequently, a history of exposure to or activities in water (eg, swimming, surfing, and kayaking)

Usually, a history of preceding ear trauma (eg, forceful ear cleaning, use of cotton swabs, or water in the ear canal)

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Physical Examination

The key physical finding of OE is pain upon palpation of the tragus (anterior to ear canal) or application of traction to the pinna (the hallmark of OE). Examination reveals erythema, edema, and narrowing of the external auditory canal (EAC), and a purulent or serous discharge may be noted (see the image below). Conductive hearing loss may be evident. Cellulitis of the face or neck or lymphadenopathy of the ipsilateral neck occurs in some patients.

Acute otitis externa. Ear canal is red and edematous, and discharge is present.

The tympanic membrane may be difficult to visualize and may be mildly inflamed, but it should be normally mobile on insufflation. Eczema of the pinna may be present. By definition, cranial nerve (CN) involvement (ie, of CNs VII and IX-XII) is not associated with simple OE.

Fungal OE results in severe itching but typically causes less pain than bacterial OE does. A thick discharge that may be white or gray is often present. Whereas pseudomonal infection produces purulent otorrhea that may be green or yellow, Aspergillus otomycosis looks like a fine white mat topped by black spheres. Upon close examination, the discharge may contain visible fungal elements (eg, spores or hyphae) or have a fuzzy appearance.

The sine qua non of necrotizing OE is pain that is out of proportion to the clinical findings. Upon close examination, granulation tissue may be present in the ear canal.

In severe cases, the infection may spread to the surrounding soft tissues, including the parotid gland. Bony extension may also occur into the mastoid bone, temporomandibular joint, and base of the skull, in which case cranial nerves VII (facial), IX (glossopharyngeal), X (vagus), XI (accessory), or XII (hypoglossal) may be affected.

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Complications

Complications of OE are rare and may include the following:

Necrotizing OE (the most significant complication)

Mastoiditis

Chondritis of the auricle (from spread of acute OE to the pinna, particularly in patients with newly pierced ears)

Bony erosion of the base of the skull (skull base osteomyelitis
[15] )

Herpes zoster may initially present with symptoms similar to those of OE, and vesicular eruption may occur 1-2 days after the initial symptoms. Ramsay Hunt syndrome is a rare complication of herpes zoster and presents with peripheral unilateral facial palsy. Patients should be counseled on this possible presentation and advised to seek medical care if it occurs.
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Russell D White, MD Professor of Medicine, Professor of Orthopedic Surgery, Director of Sports Medicine Fellowship Program, Medical Director, Sports Medicine Center, Head Team Physician, University of Missouri-Kansas City Intercollegiate Athletic Program, Department of Community and Family Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center-Lakewood